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Office Charting Information

Please enter the patient's appropriate EMR related information

Patient needs to be referred to BCS for consultation. They have indicated a Screening Mammogram appointment with a new breast problem.

Patient's Medical Record Number
Patient's Encounter Number
Patient's Social Security Number
Appointment Date*
Appointment Time
:  

Breast Health Screen and History

Patient Name*
Date of Birth*
Birth Gender*
Patient Address*
Your Ethnicity
Do you have any known allergies (including Latex)?*
Do you have any special needs that you would like us to be aware of or that we can provide assistance with?
How do you prefer to receive information?
Do you already have an appointment scheduled?*
Date & Time of your scheduled appointment
:  
Appointment Location

One of our Breast Center schedulers will contact you to schedule an appointment.  Please make sure you provided your best contact phone number in the designated box above.

Select you preferred days and times for an appointment
Select you preferred days and times for an appointment
  Early Morning Late Morning Early Afternoon Late Afternoon
Monday
Tuesday
Wednesday
Thursday
Friday
Check all that apply
What is the reason for your visit?*
Check all that apply
Do you have any new or current breast problems?*
Please describe the problems you are having*
Check all that apply

Patient Privacy Questionnaire

May we leave confidential messages regarding appointments, return calls, etc. with anyone who answers the telephone at your home?
May we leave confidential messages regarding appointments, return calls, etc. on your voicemail or home answering machine?
If we are unable to reach you by any of the above options, may we leave messages regarding appointments, return calls, etc. at your place of employment?

Please list anyone that we may contact to get or disclose personal information on your behalf.

Authorized Person #1
Authorized Person #2
Authorized Person #3
Physician you would like a copy of your report sent to
Physician Address

You may obtain a copy of the University Health Systems (UHS) Notice of Information Practices at any time by clicking here, calling (865) 305-9118, or by requesting one at the UHS or UHSV office. This document describes how your health information maybe used or disclosed by UHS, UHSV Facilities and it should read it carefully. Be aware that this document may be changed at any time.

Use your mouse or finger to draw your signature above
Date/Time
:  

Breast Health History

Have you had a Mammogram before?
Date of last Mammogram
Was your last Mammogram done at UT Breast Center?
Have you been previously diagnosed with Breast Cancer?
Which Breast?
Have you been previously diagnosed with any cancers other than breast?
Do you have any family members that have been diagnosed with Breast or Ovarian Cancer?
Example: Mother, age 65, breast cancer
Are You Pre or Post Menopausal?
Have you had a hysterectomy?
Do you still have your ovaries?
Have you ever taken hormone medication?
Do you currently have or previously had Breast Implants?
Do you currently have Blue Cross Blue Shield Insurance?

Procedure History

Indicate if you have had any of these breast procedures
Indicate if you have had any of these breast procedures
  Left Breast Right Breast Both Breasts
Cyst Aspiration or FNA
Core Needle Biopsy
Surgical Biopsy
Lumpectomy (for cancer)
Mastectomy
Breast Reduction
Breast Implant Placement
Breast Implant Removal
Have you ever had Radiation Therapy?
Which Breast?
Date of Radiation Completion
Have you ever had chemotherapy?
Date of Chemotherapy Completion
Have you ever had Cancer Prevention Therapy?

3D imaging for Blue Cross Blue Shield Patients

Our radiologists believe Breast Tomosynthesis/DBT is a valuable tool to provide a definitive diagnosis and reduce patient recalls for additional evaluation. Breast Tomosynthesis produces a three dimensional view of the breast tissue, which helps the radiologists identify and characterize individual breast structures without the confusion of overlapping tissue.

While Breast Tomosynthesis can benefit all screening and diagnostic mammography patients, it is especially valuable for women receiving a baseline screening, those who have dense breast tissue, and women with a personal history of breast cancer.

The Breast Tomosynthesis screening experience is similar to a traditional 2D mammogram. During the exam, multiple low-dose images of the breast are acquired at different angles. These images are then used to produce a 3D image of the breast in a series of one-millimeter slices, enabling the radiologist to scroll through the images to view the layers of the breast.

Our radiologists recommend you have DBT based on your tissue type or family history. Many insurance providers are now reimbursing for DBT, however it is important to understand that in some cases, insurance may not cover these services. You may want to check with your insurance to see if your plan offers coverage for Breast Tomosynthesis/3D mammography.

FOR EXAMPLE: BCBS currently applies the screening Tomosynthesis imaging cost to your annual deductible and will reimburse accordingly if your deductible is met. Please contact BCBS if you have questions regarding this benefit.

All services will be filed with your insurance company and reviewed in the event the service is recognized as investigational by your insurance provider.

 If you have any questions, please contact our patient representative @ 865-305-8158.

***DBT- Digital Breast Tomosynthesis, also referred to as 3D imaging or Tomo

Check boxes to confirm understanding
I understand the recommendation, the benefits, and importance to receive the DBT exam and...*
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Date/Time
:  

Breast Biopsy Questionnaire

Have you taken any of the following drugs in the past 5 days?
Do you have high blood pressure?
Do you currently have implants?
Have you every had dental work that required numbing medication (Novocain, Lidocaine)?
Did you have a negative reaction to the numbing medication?

Patient Authorization For Implant Mammography/Biopsy

Your physician has recommended that you have a mammogram/biopsy. This procedure is currently the best way to detect a change that cannot be felt or to clarify a change that can be felt. 

Breast implants require a special type of exam. This is because the implant does obscure breast tissue. Your implant will need to be gently moved out of the way for some of the images. The technologists have been trained to perform this special exam. 

As with all mammograms, some compression will be applied. For the images with the implants in view, compression will be applied to prevent motion. In the images with the implant moved back, compression will be applied normally, possibly causing some discomfort – usually lasting only a few seconds. 

It is not unusual for a rupture that was not felt by you or your physician to first be noticed on a mammogram. But, like a balloon, an implant that is old or weakened can rupture at any time, even during a mammogram/biopsy. This is a rare occurrence but cannot be ruled out, as the condition of the implant cannot be verified prior to the mammogram. 

Since the possibility of a rupture is minimal, and the benefit of mammography/biopsy is well documented, we hope that you will proceed and allow us to perform this special study.

I have read the implant advisory, and I...*
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Date/Time
:  

Breast MRI History

Reason for Breast MRI
Check all that apply
Which Breast?
Date of Diagnosis
Date of Last Mammogram
Are you currently taking hormones or have taken them in the last 6 months?
Do you have a history of Inflamed Breast Tissue (Mastitis)?
Are you pre or post menopausal?
Are between days 1 and 7 of your period right now?
Do you currently have or previously had Breast Implants?

Breast Implant Questionnaire

Please complete for all current and prior breast implants. Please enter pertinent information for each set of implants.

Name of Plastic Surgeon
Surgeon Location
Breast Implant History
Have you ever had...
Check all that apply

Open Capsulotomy: A surgical operation performed to treat and remove scar tissue which occurs around breast implants or to revise the shape of the implant pocket.

Closed Capsulotomy: An in office procedure where the breast is forcefully massaged to soften the capsule that surrounds the implant.

Have you ever had a Capsulotomy?
Which side was the Capsulotomy?
Have your current implants ever suffered any trauma?
Which side suffered trauma?
When did the trauma occur?
Initial reasons for implant placement
Plan for the implants
Surgeon to preform implant removal
Date Surgery Scheduled
Since your first implant(s) were placed, have you had any...
Check all that apply
Implant Manufacturer
Date implants were placed
Implant Type
Date implants were removed
Known Rupture?
Known Leak?
Is the implant textured or smooth?
Implant Placement

Osteoporosis Risk Factor Screening

Is there a chance that you are pregnant?
Have you had or do you plan on having a barium X-ray within 2 weeks of your exam?

Please contact the scheduling department to reschedule your Dexa scan so that it is more than 2 weeks apart from your barium X-Ray.

Have you ever had a bone density test before?
Has a parent or adult sibling ever broken a bone?
Have you ever broken a bone?
Example: Broke Right Hip, fell down stairs, age 68
Indicate if you have ever had surgery of the...
Indicate if you have ever had surgery of the...
  Right Side Left Side
Spine
Hip
Leg
Arm
Have you ever taken any of the following medications?
Check all that apply
Have you ever taken Steroid Medications?
Do you take Calcium supplements, including Tums?
Do you take vitamin D?
Do you currently smoke or vape?
Are you Post-menopausal?
Have you had a hysterectomy?
Were the ovaries removed?
Do you still have both ovaries?

INDIVIDUAL AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION

Please list the name and location of the healthcare facility where you had your last Mammogram.

With your signed authorization, we will request breast health related records from the healthcare facility that you list below.

You have a right to revoke this authorization by doing so in writing and mailing to the Medical Record Department at the address below.

UT Medical Center, Medical Records Dept, 1924 Alcoa Hwy U-110, Knoxville, TN 37920.

Such revocation will be effective to the extent that action has not been taken in reliance on the authorization or, if the authorization was obtained as a condition of obtaining insurance coverage, only to the extent that other law provides the insurer with the right to contest a claim under the policy.

I understand that this authorization is voluntary and that I may refuse to sign this authorization, and that my refusal will not affect my eligibility for benefits, payment for coverage of services, or ability to obtain treatment.

The information used or disclosed under this authorization may be subject to redisclosure by the recipient and may no longer be protected by the regulations that protect individually identifiable health information from use or disclosure by health care providers.


Consent for Records Request*
Location*
Relationship to Patient*
Your Name*
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Date/Time*
:  

Release of Information Request

Reason for records request
Date Range Start
(i.e. Admission Date)
Date Range End
(i.e. Discharge Date)
Information being requested
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